PHP FamilyCare

Provider Appeals

Claim Payment Disputes

PHP FamilyCare has a process for documenting and responding to administrative complaints, including claim payment decisions.  Claim payment complaints can be submitted over the telephone by calling your Provider Relations Coordinator.   A claim payment complaint may also be submitted in writing to Network Services at the following address:

Adverse Determination Appeals

An adverse determination means that a healthcare service has been clinically reviewed and is either not approved or not a covered benefit.  An explanation of the appeals process is provided with the written adverse determination.  Participating practitioners and providers who disagree with an adverse determination may initiate an appeal by writing to the Customer Service Department Appeals/Grievance Team at the following address

PHP FamilyCare 
Attn: Provider Appeals                                                                                                                                                                            PO Box 30377
Lansing MI 48909-7877

The practitioner/provider will receive a written decision within thirty (30) days of receipt.  Expedited appeals for concurrent services or services that should not be delayed due to medical condition will be determined within (72) seventy-two hours of receipt.

Binding Arbitration

PHP FamilyCare will work in good faith to resolve any disputes with its practitioners and providers about their business relationship. If the parties are unable to resolve the dispute after exhausting all internal appeal processes, participating practitioners and providers may request to pursue the dispute through binding arbitration in accordance with the rules of the American Arbitration Association. In no event may arbitration be initiated more than one year following the sending of written notice of the dispute.  Any arbitration shall be conducted in Ingham County, Michigan.

Rapid Dispute Resolution Process
 

If a non-contracted hospital has exhausted all efforts to achieve reconciliation of outstanding accounts through internal means, it may submit a request to the Michigan Department of Community Health (MDCH) to pursue the Rapid Dispute Resolution Process (RDRP).  Should a hospital elect this process, the outcome will be binding.  Both parties agree to assume the burden of cost for presentation of their positions before the mediator. The cost of the mediator will be borne proportionally. If the Hospital’s position is granted, the Health Plan agrees to make payment for the disputed claim(s) within thirty (30) days.